APPLICATION FORM

NAME APPLIED FOR:

SURNAME (FAMILY)

DATE & PLACE OF BIRTHDATE & PLACE OF BIRTH AGEAGE SEXSEX

NATIONALITY:NATIONALITY: ROMANIANROMANIAN SANGUINE SANGUINE GROUP: GROUP:

HEIGHTHEIGHT ( m ) ( m )

WEIGHTWEIGHT ( Kg ) ( Kg )

NEAREST INTERNATIONAL AIRPORTNEAREST INTERNATIONAL AIRPORT BUCHAREST – OTOPENI H.COANDABUCHAREST – OTOPENI H.COANDA

MARITAL STATUS: MARRIED SINGLE DIVORCED MARITAL STATUS: MARRIED SINGLE DIVORCED WIFE’S NAME ,SURNAME / DOB / POBWIFE’S NAME ,SURNAME / DOB / POB

CHILDRENCHILDREN

NAMENAME SURNAMESURNAME DATE & PLACE OF BIRTHDATE & PLACE OF BIRTH

PERSONAL DETAILSPERSONAL DETAILS

IDENTITY CARD IDENTITY CARD PASSPORTPASSPORT

NUMBERNUMBERISSUEDISSUED(CITY) (CITY)

DATE OFDATE OFISSUE ISSUE NUMBERNUMBER ISSUED BYISSUED BY

DATE OFDATE OF ISSUEISSUE

DATE OF EXPIRYDATE OF EXPIRY

SEAMAN’S AVAILABILITY DATESEAMAN’S AVAILABILITY DATE US VISAUS VISA

PERSONAL NUMERIC CODEPERSONAL NUMERIC CODE

NEXT OF KIN AND NEXT OF KIN AND RELATIONSHIPRELATIONSHIP PHONE NO.: PHONE NO.:

ADDRESS: ADDRESS: PHONE NOPHONE NO

E-MAIL ADDRESS:E-MAIL ADDRESS:

STUDIES / COURSES / SKILLSSTUDIES / COURSES / SKILLS

INSTITUTES’ NAMEINSTITUTES’ NAME FROMFROM TOTO CERTIFICATESCERTIFICATES

FOREIGN LANGUAGES: WRITTEN / SPEFOREIGN LANGUAGES: WRITTEN / SPEAKINGAKING LEVEL LEVEL

1.1. __ENGLISH__ENGLISH_________________ _________________ VERY GOOD VERY GOOD GOOD POORGOOD POOR 2.2. _____________________________ VERY GOOD _____________________________ VERY GOOD GOOD POOR GOOD POOR

DETAILS OF LICENCESDETAILS OF LICENCES

QUALIFICATIONSQUALIFICATIONS DOC.NRDOC.NR RANKRANK DATEDATE ISSUINGISSUING AUTHORITYAUTHORITY

ISSUEDISSUED EXPIREEXPIRENATIONAL LICENCE ( COC )NATIONAL LICENCE ( COC ) ROMANIAROMANIAFLAG STATE LICENCE 1FLAG STATE LICENCE 1FLAG STATE LICENCE 2FLAG STATE LICENCE 2GOC – NATIONAL GOC – NATIONAL ROMANIAROMANIATANKER FAMILIARIZATIONTANKER FAMILIARIZATION ROMANIAROMANIACHEM.TANKER HIGHEST GRADECHEM.TANKER HIGHEST GRADE ROMANIAROMANIAOIL TANKER HIGHEST GRADEOIL TANKER HIGHEST GRADE ROMANIAROMANIALPG TANKER HIGHEST GRADELPG TANKER HIGHEST GRADESEAMAN’S BOOKSEAMAN’S BOOK ROMANIAROMANIA

I.M.O. CERTIFICATES / VALIDITYI.M.O. CERTIFICATES / VALIDITY

GENERAL OPERATOR’S CERTIFICATE FOR GMDSS ( GOC )GENERAL OPERATOR’S CERTIFICATE FOR GMDSS ( GOC )

TRANSPORT & HANDLING OF DANGEROUS,HAZARDOUS & HARMFUL CARGOESTRANSPORT & HANDLING OF DANGEROUS,HAZARDOUS & HARMFUL CARGOESPREVENTION OF POLLUTION OF THE MARINE ENVIRONMENT – MARPOL 73/78PREVENTION OF POLLUTION OF THE MARINE ENVIRONMENT – MARPOL 73/78PROFICIENCY IN SURVIVAL CRAFT & RESCUE BOATS,OTHER THAN FAST RESCUE B.PROFICIENCY IN SURVIVAL CRAFT & RESCUE BOATS,OTHER THAN FAST RESCUE B.FAST RESCUE BOATSFAST RESCUE BOATSMARITIME ENGLISH.PROBLEM OF COMMUNICATION IN HUMAN RELATIONSHIPSMARITIME ENGLISH.PROBLEM OF COMMUNICATION IN HUMAN RELATIONSHIPSPERSONAL SURVIVAL TECHNIQUESPERSONAL SURVIVAL TECHNIQUESRADAR NAVIGATION,RADAR PLOTTING & USE OF ARPA : MANAGEMENT/OPERATIONALRADAR NAVIGATION,RADAR PLOTTING & USE OF ARPA : MANAGEMENT/OPERATIONAL

ADVANCED/BASIC FIRE FIGHTINGADVANCED/BASIC FIRE FIGHTINGMEDICAL FIRST AIDMEDICAL FIRST AIDMEDICAL CAREMEDICAL CAREPERSONAL SAFETY & SOCIAL RESPONSIBILITIES ON BOARD SHIPSPERSONAL SAFETY & SOCIAL RESPONSIBILITIES ON BOARD SHIPSSHIP SECURITY OFFICERSHIP SECURITY OFFICERBRIDGE / ENGINE TEAM MANAGEMENTBRIDGE / ENGINE TEAM MANAGEMENTENDORSEMENT CERTIFICATE VALID UNTILENDORSEMENT CERTIFICATE VALID UNTIL

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SPECIALIZED VESSELS I.M.O. COURSES / VALIDITYSPECIALIZED VESSELS I.M.O. COURSES / VALIDITY

TANKER FAMILIARIZATIONTANKER FAMILIARIZATION

SPECIALIZED TRAINING FOR OIL TANKER ( IGS & COW )SPECIALIZED TRAINING FOR OIL TANKER ( IGS & COW )SPECIALIZED TRAINING FOR CHEMICAL TANKER SPECIALIZED TRAINING FOR CHEMICAL TANKER SPECIALIZED TRAINING FOR LIQUEFIED GAS TANKERSPECIALIZED TRAINING FOR LIQUEFIED GAS TANKERPROFICIENCY IN CROWD MANAGEMENT ON RO-RO / PASSENGER SHIPSPROFICIENCY IN CROWD MANAGEMENT ON RO-RO / PASSENGER SHIPSPROFICIENCY IN PASSENGER SAFETY, CARGO SAFETY, HULL INTEGRITY ON PROFICIENCY IN PASSENGER SAFETY, CARGO SAFETY, HULL INTEGRITY ON RO-RO/PASSENGER SHIPSRO-RO/PASSENGER SHIPSRO-RO / PASSENGER SHIPS FAMILIARIZATION TRAININGRO-RO / PASSENGER SHIPS FAMILIARIZATION TRAINING

MEDICAL CERTIFICATES / VACCINATIONMEDICAL CERTIFICATES / VACCINATION

TYPETYPE PLACE OF ISSUEPLACE OF ISSUE ISSUE DATEISSUE DATE VALID UNTILVALID UNTIL

NATIONAL HEALTH CERTIFICATENATIONAL HEALTH CERTIFICATE

YELLOW FEVER VACCINATIONYELLOW FEVER VACCINATION

PREVIOUS SEA SERVICEPREVIOUS SEA SERVICE

RANKRANK VESSEL’S NAME / DELIVERYVESSEL’S NAME / DELIVERY DATE / FLAGDATE / FLAG

TYPETYPE DWTDWT ENG/ENG/ BHPBHP

SIGN SIGN

ON/OFFON/OFF

AGENCY/OWNERAGENCY/OWNER TEL.NUMBERS FORTEL.NUMBERS FOR

CONTACTCONTACT

" I understand, that my working contract will be cancelled without notifying if any of submitted documents are voted as false". Date :

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